Preterm Labour in Pregnancy and Complications
Preterm labor
Preterm labour is defined as babies born alive before 37 weeks of pregnancy completed.
EXTREMELY PRETERM : < 28 weeks
VERY PRETERM : 28 to < 32 weeks
MODERATE TO LATE PRETERM : 32 to < 37 weeks
Induction or caesarian birth should not be planned before 39 weeks completed unless medically indicated
Gestational age Versus Birth weight
Low birth weight (<2500 g)
Very low birth weight (<1500 g)
Extreme low birth weight (<1000 g)
Only two third of low birth weight infants are preterm.
Term infants may be low birth weight because they are small for gestational age
Preterm birth complications are the leading cause of the death among children under 5 years of age, responsible for nearly 1 million death in 2013.
Total incidence is 5-10%
Complication of preterm birth :
Neonatal death
RDS
Hypothermia
Hypoglycemia
Necrotizing entero-colitis
Jaundice
Infection
Retinopathy of prematurity
Risk factors
HISTORY plays a role in PTL
H/O preterm delivery or spontaneous abortion
Pregnancy following ART (IUI, ICSI)
Asymptomatic bacteuria / recurrent UTI
Smoking habits / Maternal stress/ low socio economic and nutritional stress
Risk Factors
1.COMPLICATIONS IN PRESENT PREGNANCY:
2.IDIOPATHIC:
Seen in majority cases where premature effacement of the cervix with irritable uterus and early engagement of the head is often associated.
3.MATERNAL PREGNANCY COMPLICATION
Preeclampsia
Antepartum hemorrhage
Premature rupture of membranes
Polyhydramnios
MATERNAL :
UTERINE ABNORMALITIES
Cervical incompetence
Malformation of uterus
Medical and surgical illness : Acute fever, polynephritis, acute appendicitis, diabetes, decompensated heart lesion, severe anemia low body mass index
Genital tract infection: Bacterial vaginosis, beta hemolytic streptococcus, chlamydia
FETAL :
Congenital malformation, Intrauterine death
PLACENTA:
Infarction, Thrombosis, Placenta pervia
.
Signs and symptoms
Regular uterine contraction every 10 mins or more
Fluid leaking from vagina
Cramping in lower abdomen
Increased vaginal bleeding
Increased pressure in pelvis
Vaginal spotting
Prediction of Preterm Labour
- Assesment of risk factors
- Vaginal examination to assess the cervical status
- Ultrasound visualization of cervical length and dilatation
- Detection of fetal fibronectin in cervical vaginal secretion
Diagnosis of Preterm Labour
Regular uterine contraction with or without pain(atleast one in every 10mins)
Dilatation (≥ 2cm)
Effacement (80%)
Length of cervix ≤ 2.5cm (TVS)
Funnelling of the internal OS
Pelvic pressure / back ache/ vaginal discharge or bleeding
Prevention of Preterm labor
Primary care: Reduce the incidence of PTL by reduce the risk factors
Secondary symptoms : Include screening test for early detection and prophylactic treatment (tocolytics)
Tertiary care: To reduce perinatal morbidity and mortality after the diagnosis (use of corticosteroids)
Seeking of regular prenatal care
Healthy diet and gaining weight nicely
Limiting certain physical activities
Managing chronic conditions like diabetes, increased HTN
Arresting preterm labor
Bed rest in left lateral position
Adequate hydration
Prophylactic antibiotics
Tocolytic agents (eg. Terabutaline, indomethacin, nifedipine)
Short term / long term
LEFT LATERAL POSITION
Short term therapy
Most succesful therapy
Objective:
1. Delay delivery for 48 hrs for GLUCOCORTICOID THERAPY to mother to enhance fetal lung maturation.
2. In utero transferof the patient to a unit more able to manage a preterm neonate
Glucocorticoid therapy
Recommended in pregnancy less than 34 weeks
Helps fetal lung maturation
Reduces the incidence of RDS and IVH
RISKS:
Prelabor rupture of membrane with evidence of infection
IDDM patient needs readjustment of their insulin dose
CONTRAINDICATIONS
APPROPRIATE MANAGEMENT
2 PRINCIPLES
To prevent birth asphyxia and development of RDS
To prevent birth trauma
First stage
Patient is put to bed to prevent PROM
To provide adequate fetal oxygenation
Strong sedative avoided
Epidural anesthesis is of choice
Labour should be watched by intensive clinical monitoring
In case of delay LSCS should be performed
SECOND STAGE
Birth should be gentle and slow to avoid rapid compression and decompression of head
Episiotomy may be done by LA to minimize the head decompression if there is perineal resistance
Tendency to delay is curtailed by low foreceps. Routine forceps is not indicated
The cord has to be clamped immediately at birth to prevent hypervolemia and hyperbilurubinemia
Shift the baby to NICU under the care of neonatalogist
IMMEDIATE MANAGEMENT
The cord is to be clamped quickly
Cord length is kept long in case of exchange transfusion is required
Air passage should be cleared of mucus
Adequate oxygenation
Aquaeous solution of vit K 1mg is given IM to prevent hemorrhagic manifestations
Baby should be wraped including head in a sterile warm towel
Points to be noted
Assess the mother condition to evaluate the signs of labor
Obtain a thorough obstetrics history
Determine the frequency, duration, and intensity of uterine contractions
Determine the cervical dilatation and effacement
Perform measure to stop or manage preterm labor
Bed rest in a side-lying position
Prepare for tocolytic therapy
Asses for the side effect of tocolytic therapy:
Decreased maternal bp
Dyspnea
Chest pain
FHR >180bpm
Provide physical and emotional support
Provide adequate hydration
Provide client and family education
Prognosis of preterm labour
With NICU survival rate of baby weighing b/w 1000 to 1500gm is more than 90%
With the use of surfactant, survival rate of infant born at 26wks is about 80%
Pulmonary surfactant is essential for life as it lines the alveoli to lower surface tension, thereby preventing atelectasis during breathing.
If a baby is premature (born before 37 weeks of pregnancy), he or she may not have made enough surfactant yet. When there is not enough surfactant, the tiny alveoli collapse with each breath. As the alveoli collapse, damaged cells collect in the airways. They further affect breathing.